Mistakes Happen – So Manage Them

There is typically a paradox whenever an organization deals with errors. On the one hand, because mistakes are bound to happen, senior management needs to encourage error reporting and related learnings by cultivating a constructive perspective. On the other hand, it is equally important for an organization — especially a high-reliability one such as a nuclear power plant or airline — to attempt to avoid mistakes by calling for responsible conduct and reminding employees of the importance of minimizing or eliminating errors in task execution. The resolution of this paradox calls for a combination of error prevention and error management. This can appear difficult. After all, while error prevention typically views all errors as unacceptable, error management emphasizes constructive responses such as learning from errors based on error acceptance.

This article offers insights into employees’ perceptions and tacit norms around honest mistakes and recommends strategies and actions that managers can adopt to help organizations deal with the mistake paradox.

Not all errors are created equal or viewed the same way. As Sidney Dekker, an expert studying system failure and human error, pointed out in Just Culture: Balancing Safety and Accountability, people tend to view wilful violations as unacceptable, while honest mistakes are seen as acceptable. As a result, in order to build a just and accountable error management culture, it is imperative for managers and organizations to bring clarity to what is forgivable and what is not while also facilitating error reporting among employees. But to do this effectively, organizational leaders must first understand employees’ tacit norms and perceptions of what constitutes an honest mistake.

For this paper, we interviewed 19 North American pharmacists and technicians (12 staff pharmacists and seven pharmacy technicians) from 10 different community pharmacies to help us understand what employees perceive to be “honest mistakes” and why. Using our findings, we recommend specific actions that managers and organizations can take to encourage reporting and learning from honest mistakes at all levels within the organization.

DEFINING HONEST MISTAKES

Examining the data, we found that almost all interviewees admitted or witnessed medication errors made at work, and examples of honest mistakes offered by the interviewees range from delivering the wrong medicine/dose and giving medicine to the wrong patient to failing to provide proper instructions. We independently examined the interview transcripts, and four categories of errors were identified and are listed below (see Table 1).

CHANCE OCCURRENCES: Mistakes that are attributed to unfortunate probability or bad luck.

ACTION OF OTHERS: Most mistakes, at least in pharmacies, involve multiple people. This category of mistakes refers to those that originate primarily because of someone else’s actions.

ATTENTION DEFICIT: Mistakes caused by a lack of attention due to situational factors (e.g., workload strain, time pressure, new staff, or brand new processes/issues).

WELL-INTENTIONED MISTAKES: Mistakes that employees committed out of a good purpose (e.g., meant for customers’ convenience, but deviated from standard processes without checking with doctors/patients first).

The first three identified types of honest mistakes were described by interviewees as unintentional errors involving no intent to harm. Only the final category of mistake involves purposeful, if misguided, action on the part of the person committing the error.

Honest mistakes, when reported, present valuable opportunities for organizational learning and better control of errors through the examination of contributing factors and processes. But managers must adjust their approach to dealing with honest mistakes based on their root causes. Our data revealed that key sources of honest mistakes range from individual actions and choices (e.g., intentionally not following accepted or best practices) to process or system factors that are under the control of management (e.g., lack of attention due to workload pressure). Mistakes from individual choices may result in changes targeted towards one individual (e.g., retraining or re-assignment of an employee), while mistakes from process/system issues may result in broader changes to reduce the likelihood of others making similar mistakes. For example, managers may notice that most “unintentional” mistakes caused by workload strain occur at around the same time every day, which suggests that more staff should be supplied to accommodate customer demands during that specific period of time.

FAILURE TO REPORT HONEST MISTAKES

Despite all the potential learning benefits, employees can fail to report honest mistakes for various reasons. Workers, for example, may not report errors seen as chance occurrences because they believe, by definition, that little can be learned from mistakes with roots beyond anyone’s control. However, mistakes that employees see as due to uncontrollable bad luck may not really be so because misattribution often occurs. Workers may wrongly attribute mistakes to chance factors because they do not have enough knowledge or information to identify the root causes of errors. To encourage the reporting of this type of error, managers should make employees aware of the possibility of making mistaken attributions, in addition to educating employees about the benefits of reporting such mistakes. Furthermore, managers can encourage error reporting by ensuring that employees are given complete and reliable information about work systems so that they can avoid incorrect error attributions.

Mistakes caused by someone else’s poor actions can also not be reported — but for different reasons. These errors may not get reported because the mistake-maker is from within the organization and workers want to protect a colleague/friend; workers may also fail to report the incident out of political considerations (e.g., avoiding unwanted misunderstandings or hostility). When caused by someone from outside the organization, these errors may not be reported by employees because they perceive the difficulty in controlling these errors. For example, when medication mistakes are attributed to the illegible writing (or mistakes) of a doctor, the doctor needs to be alerted to difficulties that he or she has created, but a pharmacist or technician may not feel empowered to go beyond their own organization’s boundaries to influence physician behaviour.

To encourage the reporting of errors believed to be caused by someone inside the organization, managers should promote psychological safety in their workplace. As noted by Lucy H. MacPhail and Amy C. Edmondson in an article entitled “Learning Domains: The Importance of Work Context in Organizational Learning from Error,” in the book Errors in Organizations, environments that are high in psychological safety reduce individuals’ fears of interpersonal risks by minimizing interpersonal or interdepartmental politics and by emphasizing objective and bias-free analyses of errors.

To encourage the reporting of errors believed to be caused by someone outside the organization, managers can emphasize the learning benefits of such error reporting. For such benefits to be credible, the organization should establish learning practices (such as problem-solving teams or process-improvement initiatives) in response to reported errors. Employees are more likely to report such errors when they see reports leading to system improvements that impact many actors regardless of whether they are from within the same organization.

Errors attributed to situational factors may also be overlooked because employees tend to view these mistakes as just a “normal” part of their work. A similar view is often held of well-intentioned mistakes. Employees may believe these errors are not report-worthy and that there is no need to devote effort to error analysis because “it is no one’s fault” and because little harm usually results. In particular, interviewees described these errors as “minor” or not really a mistake “if customers are fine with it.” However, as Drekker’s research suggests, there are no minor mistakes at a workplace. And supposedly minor mistakes, especially recurring ones, can represent excellent learning opportunities.

Keep in mind that severe mistakes can be prevented by addressing relatively minor errors in an open, low-pressure, psychologically safe environment. Consider that industrial accidents often result from the conjunction of multiple necessary but singly insufficient factors, as noted in Normal Accidents: Living with High-Risk Technologies by sociologist Charles Perrow.

Simply put, reporting even minor errors can be critically important in high-reliability organizations. At the same time, given the work required to analyze each error, a balance must be made between reporting near misses and generating too many error reports. Judgment is required on the part of employees as to the possible implications of an error — and this should likely be the benchmark as to whether to report an incident or not.

To encourage the manageable reporting of errors and near misses, organizations should ensure that employees have access to complete and reliable information about the interconnections and interdependencies of the subsystems that constitute their work environment. By understanding the entire work system, employees can make informed judgments regarding how errors in one subsystem may affect the rest of the organization and patients/customers alike.

Lastly, because individuals are prone to what researchers call a “self-serving bias,” employees may incorrectly attribute their mistakes to any of the three unintentional causes (chance, someone else, or situational factors) so that they can deflect blame from themselves. For example, an interviewee offered the following incident as an honest mistake caused by bad luck: “We had a situation where a woman had been discharged from hospital and we blister-packed her medications. So the basket was sitting up on top of the counter, and I had all kinds of things that I needed to tell her daughter. And it was a Saturday. So I came out to sit and have my lunch, and they would come get me if they needed anything. And the daughter came just by chance the 10 minutes that I was sitting down. And for some unknown reason, there had been blister packs from before she went in the hospital, still in the drawer. And of course for the cashier, there was no reason for concern. The cashier gave her what was in the drawer like any other time. And it was just [a] coincidence…. It was really bad luck that it happened right at that time. But anyway, it got caught later in the day.”

In this example, the mistake cannot be attributed purely to bad luck because human error is involved in the incident; someone should have removed the old medicine from the drawer, or the interviewee should have communicated with the cashier before taking a break. To uncover the root cause of an error, managers should be aware of the influence of self-serving biases in employees’ interpretations of errors and perform thorough analyses of errors reported. Only then can improved system- or individual-focused control be expected from error reporting.

CONCLUSION

Errors are prevalent in organizations, but they offer opportunities for learning. However, it is difficult for organizations to learn from mistakes when managers do not receive any first-hand knowledge of the circumstances that led to them from front-line employees. Therefore, to effectively deal with errors, organizations cannot focus on error prevention alone. It is equally important to adopt an error management approach designed to both encourage mistake reporting and maximize the beneficial outcomes of errors such as learning and innovation.

TABLE 1

Categories of “Honest Mistakes”

Examples Given by Interviewees

Unintentional

Chance Occurrences

“…honest mistakes are the ones where all of the pharmacy policies and procedures were followed. And there are times that it is just by chance that things go awry. And it’s usually a comedy of things that happen over time and different people… but everyone did what they were supposed to do.”“We had a situation where a woman had been discharged from hospital and we blister-packed her medications. So the basket was sitting up on top of the counter, and I had all kinds of things that I needed to tell her daughter. And it was a Saturday. So I came out to sit and have my lunch, and they would come get me if they needed anything. And the daughter came just by chance the 10 minutes that I was sitting down. And for some unknown reason, there had been blister packs from before she went in the hospital, still in the drawer. And of course for the cashier, there was no reason for concern. The cashier gave her what was in the drawer like any other time. And it was just [a] coincidence…. It was really bad luck that it happened right at that time. But anyway, it got caught later in the day.”

Actions of Others

“…certainly things like, you know, misreading a prescription because of illegible handwriting or an abbreviation that to me means one thing and to somebody else means something else.” “…a lot of times the doctors, with these new computer-generated prescriptions, they’re not checking the doses on them. So we’re having an awful lot of that. Doctors just leaving the last dose in or not changing it, or maybe he’s looking at one from six months ago.”

Attention Deficit

“…sometimes there’s a lot of pressure out there, because there’s a line-up of people and they’re trying to get to the next person, and trying to quickly review what’s on the screen before they F6 and print the label. And they may… those are honest mistakes I guess. They’re just not taking the extra two seconds because there’s another outside force or pressure on them… time.”“Depending on… who’s doing it — like if it’s a newer technician — we’ll go, ‘Okay, you gotta make sure you’re paying attention to this.’”

“…called in for a lady with a very similar-sounding name to another lady. And so when the second lady came in, I knew it should have been for her because it was something for a dentist. She had to go to the dentist right away. And a very easily mistaken name. Very, very similar in sound, the names were.”

Intentional

Well-Intentioned

“Probably making a change that we thought the patient would prefer without asking them…. For example, maybe there’s a pill that’s really big and it’s a little old lady getting it. And it’s available as a smaller tablet, half the strength. So we might give two of the smaller tablets thinking it’s easier for her to swallow. And in fact, it wasn’t.”